Icpc Policy

Republic of the Philippines
Province of Ilocos Norte

PIDDIG DISTRICT HOSPITAL
Brgy. #2 Anao, Piddig, Ilocos Norte
Tel. No. (077)6761406
PHIC ACCREDITED HEALTH CARE PROVIDER
TITLE OF DOCUMENT: POLICY, GUIDELINES AND STANDARD

OPERATING PROCEDURE FOR INFECTION
CONTROL AND PREVENTION
MANUAL: MEDICAL
CATEGORY: INFECTION CONTROL
AUTHOR: MARK EMIL U. BAUTISTA

Nurse I
RECOMMENDING
APPROVAL: CHONA STELLA F. RABANG, MD
Medical Officer III
Officer-In-Charge
NOTED BY: ROGELIO BALBAG, M.D.

Executive Director
Ilocos Norte Hospital Management Council
APPROVED BY: Hon. MATTHEW J. MARCOS MANOTOC

Governor, Province of Ilocos Norte
EFFECTIVITY: UPON APPROVAL

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I. Introduction
Healthcare-associated infection (HCAI) is one of the most common complications

of health care management. It is a serious health hazard as it leads to increased patients’
morbidity and mortality, length of hospital stays and the costs associated with hospital
stay.
Effective infection prevention and control is central to providing high quality health
care for patients and a safe working environment for those that work in healthcare
settings.
It is important to minimize the risk of spread of infection to patients and staff in
hospital by implementing good infection control program.
This document outlines the broad principles and practices of infection Control that
are essential for the prevention and management of infection.
II. Management Structure
There shall be a functional infection control management structure under the Office
of the Chief of Hospital, with adequate resources and clear lines of responsibility.
A. Responsibilities of the Chief of Hospital

1. Establish, organize, monitor and support the activities of the IPC Unit.
2. Designate one most qualified infection control physician and at least an
infection control nurse as managers of the IPC Unit.
3. Ensure that the IPC Unit members are qualified, trained and/or certified in an
IPC training course accredited by DOH or other accrediting bodies.
4. Monitor or track records on IPC procedures and reports provided by the IPC
Unit.
5. Address efficiently and effectively all IPC concerns and issues occurring at the
healthcare facility level.
B. Infection Control and Prevention Unit

1. The IPCU shall be directly under the Office of Chief of Hospital.
2. The IPCU shall have sufficient resources and clear lines of responsibility.
3. The IPCU shall have a functional relationship to the Infection Prevention and
Control Committee.
4. The IPCU shall be responsible for the day-to-day infection prevention and
control activities.
5. The IPCU shall have adequate regular or permanent staff and has provision of
appropriate facilities to enable it to perform its duties.
6. IPCU shall effectively performs the following functions:
 Conducts and documents surveillance activities.
 Coordinates with the Infectious Disease Specialist, Laboratory and
Administration as well as other departments both inside and outside the
Hospital about known or suspected cases of notifiable/reportable infectious
diseases, food poisoning and other significant infections such as Multi-Drug
Resistant Organism (MDRO).
INFECTION PREVENTION AND CONTROL MANUAL MEUB

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 Ensures adequate, accurate and timely reporting and feedback of

information to the concerned area/unit.
 Investigates, initiates and assesses risks of infection and recommends
allocation of resources for investigation, management and control
 Responses to urgent problems of infection control through a 24-hour
emergency referral system.
 Proposes resource requirement for the program and any contingencies.
 Gives advice on the procurement of medical equipment, drugs/medicines
and supplies.
 Participates in the planning and design of plant facilities critical to infection
prevention and control, i.e. renovations, repairs, relocation of critical care
areas.
 Develops IPC training modules, organizes the relevant education and
training programs for all healthcare staff and encourages reflexive practice
of infection control measures.
 Monitors compliance to infection prevention and control policies, guidelines
and procedures.
 Recommends/proposes IPCC actions which may have implications for
infection prevention and control in the hospital.
C. Members of the Infection Prevention and Control Unit

The qualifications for each of the Members of the IPCU are found in Annex A.
1. IPCU Head
 The IPCU Head shall be an active Medical Officer who may also serve as
the Chair or Co-Chair and has a minimum required training provided by
accredited societies and has experience in infection prevention and control.
2. Infection Prevention and Control Nurse (IPCN)
 The IPCN shall be the Supervisor Nurse in the Hospital.
 The IPCN shall have dedicated time in undertaking the role.
 The IPCN has received formal/certification training in infection prevention
and control provided by an accredited training organization.
 The IPCN coordinates all infection prevention and control activities with the
IPCU Head as well as the other areas in the healthcare facility.
3. Infection Prevention and Control Surveillance Officer (IPCSO)
 The IPCSO shall conduct surveillance on AMS, HAI, MDRO, notifiable
diseases (PIDSR) and other IPC related surveillance activities.
 The IPCSO shall be a college graduate and has received training in IPC
and IPC surveillance activities provided by an accredited training
organization.
 The IPCSO shall accomplish and prepare necessary documents and
statistics related to IPC surveillance activities.
 Assists the IPCU on all clerical and administrative activities.

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D. Infection Prevention and Control Committee (IPCC)

1. The IPCC shall be under the Office of the Chief of Hospital, with the following
functions:
 Formulates and updates infection prevention and control policies,
guidelines and procedures.
 Ensures implementation of infection prevention and control policies,
guidelines and procedures
 Disseminates information and coordinates effectively with all departments,
sections and services of the hospital and other appropriate government
agencies for the implementation of IPC.
 Organizes and provides training and guidance to the hospital IPC Unit,
which is responsible for the day-to-day IPC activities.
 Makes medicines, medical supplies, personal protective equipment, and
other equipment and materials readily available for the day-today
implementation of IPC and for contingency as well.
 Designs and implements and/or outsources the training and orientation of
all health personnel on IPC.
 Meets at least once monthly and whenever necessary in order to
consolidate, analyze and act on reports related to IPC.
 Reviews, approves and submits mandatory healthcare facility reports on
IPC to the DOH Regional Health Office.
 Prepares, reviews and evaluates the progress and the effectiveness of the
infection prevention and control program.
 Oversees the activities and performance of the IPC Unit.
 Approves infection prevention and control training modules.
 Defines the goals, objectives and priorities for all surveillance activities on
healthcare associated infections. Including time frame, area, patient
population to be studied and surveillance method to be used.
2. Members of the IPCC
a. Chairperson: Chief of Hospital or the designated person
b. Core Members:
i. Administrative Officer or equivalent;
ii. Representative from Medical Service;
iii. Representative from Nursing Service;
iv. Representative from Laboratory;
v. Representative from Emergency Room;
vi. Representative from Delivery Room;
c. Auxiliary Members:
i. Representative from Maintenance;
ii. Representative from Pharmacy;
iii. Representative from Dietary Service
iv. Representative from Linen and Laundry;

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III. Guidelines, Policies and Standard Operating Procedures
A. Hand Hygiene
1. Objectives
 To be able to improve hand-hygiene practice
 To reduce the transmission of pathogenic microorganisms to patients and
personnel in health-care settings
2. Definition of Terms
a. Ranking of Evidence for Recommendation
Agreement of CDC & HICPAC system for categorizing recommendations is
adapted as follows:
 Category IA - Strongly recommended for implementation and strongly
supported by well designed experimental, clinical, or epidemiological
studies.
 Category IB - Strongly recommended for implementation and supported by
some experimental, clinical, or epidemiological studies and a strong
theoretical rationale.
 Category IC - Required for implementation, as mandated by federal and/or
state regulation or standard.
 Category II - Suggested for implementation and supported by suggestive
clinical or epidemiological studies or a theoretical rationale or a consensus
by a panel of experts.
3. Policy Guidelines
a. Indications for Handwashing and Hand Antisepsis
 Wash hands with soap and water when visibly dirty or contaminated with
proteinaceous material, or visibly soiled with blood or other body fluids, or if
exposure to potential spore-forming organisms is strongly suspected or
proven (CATEGORY IB) or after using the restroom (CATEGORY II).
 Preferably use an alcohol-based hand rub for routine hand antisepsis in all
other clinical situations described below if hands are not visibly
soiled (CATEGORY IA). Alternatively, wash hands with soap and
water (CATEGORY IB).
o Perform hand hygiene:
o Before having direct contact with patients (CATEGORY IB)
o After removing gloves (CATEGORY IB)
o Before handling and invasive device (regardless whether or not gloves
are used) for patient care (CATEGORY IB)
o After contact with body fluids or excretions, mucous membranes, non-
intact skin, or wound dressings (CATEGORY IA)
o If moving from a contaminated body site to a clean body site during
patient care (CATEGORY IB)
o After contact with inanimate objects (including medical equipment) in the
immediate vicinity of the patient (CATEGORY IB)
 Wash hands with either plain or antimicrobial soap and water or rub hands
with an alcohol-based formulation before handling medication and
preparing food (CATEGORY IB).

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 When alcohol-based hand is already used, do not use antimicrobial soap

concomitantly (CATEGORY II)
b. Hand-hygiene Technique
 Apply a palmful of the product and cover all surfaces of the hands. Rub
hands until hands are dry (CATEGORY IB).
 When washing hands with soap and water, wet hands with water and apply
the amount of product necessary to cover all surfaces. Vigorously perform
rotational hand rubbing on both palms and interlace fingers to cover all
surfaces. Rinse hands with water and dry thoroughly with a single use towel.
Use running and clean water whenever possible. Use towel to turn off
faucet (CATEGORY IB).\
 Make sure hands are dry. Use a method that does not re-contaminate
hands. Make sure towels are not used multiple times or by multiple
people (CATEGORY IB). Avoid using hot water, as repeated exposure to
hot water may increase the risk of dermatitis (CATEGORY IB).
 Liquid, bar, leaflet or powdered forms of plain soap are acceptable when
washing hands with a non-antimicrobial soap and water. When bar soap is
used, small bars of soap in racks that facilitate drainage should be
used (CATEGORY II).
c. Surgical Hand Preparation

 If hands are visibly soiled, wash hands with a plain soap before surgical
hand preparation (CATEGORY II). Remove debris from underneath
fingernails using a nail cleaner, preferably under running
water (CATEGORY II).
 Sinks should be designed to decrease the risk of splashes (CATEGORY II).
 Remove rings, watches, and bracelets before beginning surgical hand
preparation (CATEGORY I). Artificial nails are prohibited (CATEGORY IB).
 Surgical hand antisepsis should be performed using either an antimicrobial
soap or an alcohol-based hand rub, preferably with sustained activity,
before donning sterile gloves (CATEGORY IB).
 If quality of water is not assured in the operating theatre, surgical hand
antisepsis using an alcohol-based hand rub is recommended before
donning sterile gloves when performing surgical procedures (CATEGORY
II).
 When performing surgical hand antisepsis using an antimicrobial soap,
scrub hands and forearms for the length of time recommended by the
manufacturer, 2 to 5 min. Long scrub times (e.g. 10 min) are not
necessary (CATEGORY IB).
 When using an alcohol-based surgical hand rub product with sustained
activity, follow the manufacturer’s instructions. Apply the product on dry
hands only (CATEGORY IB). Do not combine surgical hand scrub and
surgical hand rub with alcohol-based products sequentially (CATEGORY
II).

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 When using an alcohol-based product, use sufficient product to keep hands

and forearms wet with the hand rub throughout the
procedure. (CATEGORY IB).
 After application of the alcohol-based product, allow hands and forearms to
dry thoroughly before donning sterile gloves (CATEGORY IB).
d. Selection and Handling of Hand-Hygiene Agents

 Provide health-care workers with efficacious hand hygiene products that
have low irritancy potential (CATEGORY IB).
 To maximize acceptance of hand hygiene products by health-care workers,
solicit their input regarding the feel, fragrance, and skin tolerance of any
products under consideration. In some settings, cost may be a primary
factor (CATEGORY IB).
 When selecting hand hygiene products:
 Determine any known interactions between products used to clean hands,
skin care products, and the types of gloves used in the
institution (CATEGORY II);
 Solicit information from manufacturers about risk of contamination (pre-
marketing and in-use) (CATEGORY IB);
 Ensure that dispensers are accessible at the point of care (CATEGORY
IB);
 Ensure that dispenser’s function adequately and reliably, and deliver an
appropriate volume of the product (CATEGORY II);
 Ensure that the dispenser system for alcohol-based formulations is
approved for flammable materials (CATEGORY IC);
 Solicit information from manufacturers regarding any effects that hand
lotions, creams, or alcohol-based hand rubs may have on the effects of
antimicrobial soaps being used in the institution (CATEGORY IB).
 Do not add soap to a partially empty soap dispenser. If soap dispensers are
reused, follow recommended procedures for cleansing (CATEGORY 1A)
e. Use of Gloves
 The use of gloves does not replace the need for hand cleansing by either
hand rubbing or hand washing (CATEGORY IB).
 Wear gloves when it can be reasonably anticipated that contact with blood
or other potentially infectious materials, mucous membranes, and non-
intact skin will occur (CATEGORY IC).
 Remove gloves after caring for a patient. Do not wear the same pair of
gloves for the care of more than one patient (CATEGORY IB).
 When wearing gloves, change or remove gloves during patient care if
moving from a contaminated body site to a clean body site within the same
patient or to the environment (CATEGORY II).
 Avoid reuse of gloves (CATEGORY IB). If gloves are re-used, implement
reprocessing methods to ensure glove integrity and microbiological
decontamination (CATEGORY II).

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f. Fingernails of Healthcare Worker

 Do not wear artificial fingernails or extenders when having direct contact with
patients (CATEGORY IA).
 Keep natural nails short (tips less than 0.5 cm long) (CATEGORY II).
g. Healthcare Worker Educational Training and Motivational Program

 The hand hygiene promotion programmes for health-care workers is
focused specifically on factors currently found to significantly influence
behavior, and not solely on the type of hand hygiene products. The strategy
must be multifaceted and multimodal and include education and senior
executive support for implementation (CATEGORY IB).
 Educate health-care workers about the type of patient-care activities that
can result in hand contamination and about the advantages and
disadvantages of various methods used to clean hands (CATEGORY II).
 Monitor health-care workers’ adherence to recommended hand hygiene
practices and provide them with performance feedback (CATEGORY IA).
 Encourage partnerships between patients, their families and health-care
workers to promote hand hygiene in health care (CATEGORY II).
h. Institutional Responsibility and Role of Administrators

 Provide health-care workers with access to safe continuous water supply at
all faucets and access to necessary facilities to perform hand
washing (CATEGORY IB).
 Provide health-care workers with a readily accessible alcohol-based hand
rub at the point of patient care (CATEGORY IA).
 Make improved hand hygiene adherence an institutional priority and provide
appropriate leadership, administrative support and financial
resources (CATEGORY IB).
 Assign health-care professionals with dedicated time and training for the
institutional infection control activities, including the implementation of a
hand hygiene promotional program (CATEGORY II).
 Implement a multidisciplinary, multifaceted and multimodal program
designed to improve adherence of health-care workers to recommend hand
hygiene practices (CATEGORY IB).
 With regard to hand hygiene, ensure that the water supply within the health-
care setting is physically separated from drainage and sewerage, and
provide routine system monitoring and management (CATEGORY IB).
 Store supplies of alcohol-based hand rubs in cabinets or areas approved
for flammable materials
i. Performance Indicators
The following performance indicators are recommended for measuring
improvements in HCWs' hand-hygiene adherence:
 Periodically monitor and record adherence as the number of hand-hygiene
episodes performed by personnel/number of hand-hygiene opportunities,

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by ward or by service. Provide feedback to personnel regarding their

performance.
 Monitor the volume of alcohol-based hand rub (or detergent used for hand
washing or hand antisepsis) used per 1,000 patient-days.
 Monitor adherence to policies dealing with wearing of artificial nails.
 When outbreaks of infection occur, assess the adequacy of health-care
worker hand hygiene.
B. Standard and Transmission-Based Precaution

1. Objectives
 Standard Precautions are designed to reduce the risk of transmission of
microorganisms from both recognized and unrecognized sources of
infection in healthcare settings. Standard Precautions apply to all patients
and in all situations, regardless of diagnosis or presumed infection status.
Because all patients can serve as reservoirs for infectious agents, adhering
to Standard Precautions during the care of all patients is essential to
interrupting the transmission of microorganisms.
2. Policy
 All hospital staff will assess situations and implement appropriate Standard
and Transmission-Based Precautions based on the procedure or practice.
 Standard Precautions are sufficient to interrupt the spread of most infectious
agents.
 Transmission-based precautions are used in addition to Standard
Precautions.
3. Chain of infection
 A break in the chain of infection can prevent the transmission of infection.
a. Infectious Agent
 An infectious agent is any disease-causing microorganism such as a
bacterium, virus, parasite, or fungus. Characteristics of an disease-
causing organism include the organism’s virulence (ability to multiply
and grow), invasiveness (ability to enter tissue), and pathogenicity
(ability to cause disease).
b. Reservoir
 A reservoir is the location or physical place that harbors microorganisms
(pathogenic, opportunistic or non-pathogenic) and serves a possible
source of infection. Reservoirs of disease can be inanimate such as
toilet seats, elevator buttons, or animate such as food, water or human
bodily fluids.
c. Portal of Exit
 The portal of exit is the physical location from which an organism leaves
an animate reservoir, such as the respiratory tract (nose, mouth),
intestinal tract (rectum), urinary tract, or blood and other body fluids.
d. Mode of Transmission
 The mode of transmission is the means by which an organism transfers
from one carrier to another by either direct transmission (direct contact
between infectious host and susceptible host) or indirect transmission
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(which involves an intermediate carrier like an environmental surface or

a piece of equipment).
e. Portal of Entry
 The portal of entry is the physical location through which a pathogen
enters the host’s body such as mucus membranes, open wounds, or
tubes inserted in body cavities like urinary catheters, central lines or
feeding tubes.
f. Susceptible Host
 A susceptible host is a person who is at risk for developing an infection.
Several factors make a person more susceptible to disease including
age (young people and elderly people generally are more at risk),
underlying chronic diseases such as diabetes or asthma, conditions that
weaken the immune system like HIV, certain types of medications,
invasive devices like feeding tubes or central lines, and malnutrition.
4. Sources/Reservoirs of Infection
 The source and/or associated reservoirs of infectious agents are
categorized into three distinct types: human, animal and environmental. It
is important to be aware of the of what the typical sources and reservoirs
are of the common pathogens found in healthcare facilities in order to better
control and prevent the spread of disease.
 The infectious agent depends on the reservoir for survival, where it can
reproduce itself in such manner that it can be transmitted to a susceptible
host.
a. Human
 Many common infectious diseases have human reservoirs. Diseases
that are transmitted from person to person without intermediaries
include the sexually transmitted diseases, measles, mumps,
streptococcal infection, and many respiratory pathogens. Because
humans were the only reservoir for the smallpox virus, naturally
occurring smallpox was eradicated after the last human case was
identified and isolated.
b. Animal
 Humans are also subject to diseases that have animal reservoirs. Many
of these diseases are transmitted from animal to animal, with humans
as incidental hosts. The term zoonosis refers to an infectious disease
that is transmissible under natural conditions from vertebrate animals to
humans. Long recognized zoonotic diseases include brucellosis (cows
and pigs), anthrax (sheep), plague (rodents), trichinellosis/trichinosis
(swine), tularemia (rabbits), and rabies (bats, raccoons, dogs, and other
mammals).
c. Environmental
 Plants, soil, and water in the environment are also reservoirs for some
infectious agents. Many fungal agents, such as those that cause
histoplasmosis, live and multiply in the soil. Outbreaks of Legionnaires
disease are often traced to water supplies in cooling towers and

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evaporative condensers, reservoirs for the causative

organism Legionella pneumophila.
4. Routes of Transmission
 The transmission of an infectious organism to a susceptible host occurs
through three modes: direct contact, droplet and indirect.
a. Direct Contact
 Occurs through skin-to-skin contact, kissing, and sexual intercourse.
Direct contact also refers to contact with soil or vegetation harboring
infectious organisms. Thus, infectious mononucleosis (“kissing
disease”) and gonorrhea are spread from person to person by direct
contact. Hookworm is spread by direct contact with contaminated soil.
b. Droplet
 It refers to spray with relatively large, short-range aerosols produced by
sneezing, coughing, or even talking. Droplet spread is classified as
direct because transmission is by direct spray over a few feet, before the
droplets fall to the ground. Pertussis and meningococcal infection are
examples of diseases transmitted from an infectious patient to a
susceptible host by droplet spread.
c. Indirect Contact
 It refers to the transfer of an infectious agent from a reservoir to a host
by suspended air particles, inanimate objects (vehicles), or animate
intermediaries (vectors).
i. Airborne transmission
 It occurs when infectious agents are carried by dust or droplet
nuclei suspended in air. Airborne dust includes material that has
settled on surfaces and become resuspended by air currents as
well as infectious particles blown from the soil by the wind.
Droplet nuclei are dried residue of less than 5 microns in size. In
contrast to droplets that fall to the ground within a few feet, droplet
nuclei may remain suspended in the air for long periods of time
and may be blown over great distances. Measles, for example,
has occurred in children who came into a physician’s office after
a child with measles had left, because the measles virus
remained suspended in the air.
ii. Vehicles
 Those that may indirectly transmit an infectious agent include
food, water, biologic products (blood), and fomites (inanimate
objects such as handkerchiefs, bedding, or surgical scalpels). A
vehicle may passively carry a pathogen — as food or water may
carry hepatitis A virus. Alternatively, the vehicle may provide an
environment in which the agent grows, multiplies, or produces
toxin — as improperly canned foods provide an environment that
supports production of botulinum toxin by Clostridium botulinum.
iii. Vectors
 It includes mosquitoes, fleas, and ticks may carry an infectious
agent through purely mechanical means or may support growth

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or changes in the agent. Examples of mechanical transmission

are flies carrying Shigella on their appendages and fleas
carrying Yersinia pestis, the causative agent of plague, in their
gut. In contrast, in biologic transmission, the causative agent of
malaria or guinea worm disease undergoes maturation in an
intermediate host before it can be transmitted to humans.
5. Control Measures
 Control of the transmission of infectious diseases is organized into three
levels: 1) Engineering, 2) Administrative, and 3) Personal Protective
Equipment.
a. Engineering
 Engineering controls protect workers by removing hazardous
conditions or by placing a barrier between the worker and the hazard.
Examples include local exhaust ventilation to capture and remove
airborne emissions or machine guards to shield the worker.
b. Administrative
 Administrative controls are training, procedure, policy, or shift
designs that lessen the threat of a hazard to an individual.
Administrative controls typically change the behavior of people (e.g.,
factory workers) rather than removing the actual hazard or providing
personal protective equipment (PPE).
c. Personal Protective Equipment
 An equipment worn to minimize exposure to hazards that cause
serious workplace injuries and illnesses. These injuries and illnesses
may result from contact with chemical, radiological, physical,
electrical, mechanical, or other workplace hazards. Personal
protective equipment may include items such as gloves, safety
glasses and shoes, earplugs or muffs, hard hats, respirators, or
coveralls, vests and full body suits.
6. Organizational, Administrative and Health Care Worker Responsibilities
 When it comes to controlling and preventing the spread of infectious
diseases within the hospital, there are three levels of responsibility. This
is similar to, and is in accordance with, the hierarchy of control
measures. The first level of responsibility associated with control of
disease transmission falls on the organization itself. The second level
involves the hospital’s administration, and the third level relates to that
of the healthcare worker.
 In general, healthcare worker responsibilities for controlling and
preventing the spread of disease occur through three activities
(separately or in combination): 1) performing a point of care risk
assessment (PCRA), 2) compliance with standard precautions, and 3)
compliance with transmission-based precautions.
a. Organization Engineering Control Responsibilities
 Healthcare facility design, renovation and construction
 Heating, ventilation and air conditioning
 Source control

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b. Administrative Control Responsibilities

 Occupational health
 Education of staff
 Repossessing of patient care equipment
 Environmental cleanup
 Waste
 Linen
 Management of deceased patients/residents
 Management of pets/animals
c. Health Care Worker’s Responsibilities
i. Primary Care Risk Assessment
 Prior to every patient/resident interaction, all healthcare providers
(HCPs) have the responsibility to assess the infectious risk posed
to themselves, other HCPs, patients, or visitors. The ability to
perform a thorough point of care risk assessment of the patient
or resident and their environment is fundamental to practicing
infection control
ii. Standard Precaution
 Standard precautions are a group of infection prevention
practices which include hand hygiene and the use of gloves,
gowns, masks, eye protection or face shields depending on the
anticipated exposure. The basic premise of standard precautions
is to treat all patients’/residents’ blood or body fluid as if they are
infectious.
iii. Transmission-Based Precaution
 The second tier of basic infection control and are to be used in
addition to Standard Precaution for patients who may be infected
or colonized with certain infectious agents for which additional
precautions are needed to prevent infection transmission.
C. Triage of Infectious Patients

1. Objectives:
 Enhance early recognition of patients who may be having contagious
infectious disease on arrival to the facility.
 Early Implementation of infection prevention and control measures and so
minimizing cross transmission and health care associated infections.
2. Setting up a triage system for infectious diseases
 The Hospital should ensure that a triage system/ process for infectious
diseases is available, implemented, and monitored. It should include
defined process with clear roles and responsibilities ensuring the following:
a. Early recognition of patients with communicable diseases like COVID-
19, viral hemorrhagic fever, TB, measles, …etc.
b. Early containment to prevent exposing healthcare staff and other
patients unnecessarily in waiting areas and during patient encounters.
c. Informing the infection control team in the health care institution.
d. Reporting to the proper agency per DOH guidelines.

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 The procedures at first encounter of patient need to include gathering

appropriate information early in the patient encounter, specifically collecting
the chief complaint and travel history as well as risk factors relevant to
specific diseases. It should include recent serious communicable disease
threats and ensure that procedures and protocols are updated to address
them.
a. Instruction to the patients for declaring symptoms and/ or risk factors for
having transmissible infectious disease which can include some or all of
the following:
 Instruction message displayed at the entrance to the facility as a
poster or screen display.
 Declaration forms filled at registration
 Screening interview by the triage staff
b. Providing facilities for an early containment of exposure risks at entry to
the facility
 Hand hygiene facilities (hand rub/ hand wash)
 Paper towel/ tissues o Pedal bin for waste disposal
 Surgical mask for patients with respiratory symptoms (cough,
sneezing)
c. Displaying awareness material for public on common/emerging
infections and preventive measures like hand hygiene and cough
etiquette
d. Continuous update for the triage staff especially in the event of emerging
/re-emerging infections of public health importance including
Identification of suspected case as a clinical syndrome and if there is
any epidemiological factors and management algorithm.
e. Providing necessary PPE for the triage staff and training on appropriate
use
f. Ensure that the triaging for infectious disease does not interfere with the
clinical assessment and urgent management of acutely sick patients in
the emergency department/ OPD rather alerting the staff on the needed
measures to avoid exposure in the context of the patient care.
g. The Hospital needs to have a process for receiving suspect cases with
contagious infectious diseases arriving by ambulance to be directed to
an isolation facility where patient can be assessed and manage without
exposing others in the emergency department.
h. There is a process that occurs after a suspect case is identified to
include immediate notification of infection control team in the institution.
i. There is a process to notify local or national disease surveillance and
control department of a suspect contagious infectious diseases case in
align with DOH guidelines for reporting and surveillance.
3. Triage Process
 The procedures of screening & containment of communicable diseases can
be divided into 3 steps that should be incorporated to the existing process
of triage (severity scale in the ER or admission system):

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i. Providing Information and facilities to patient/ accompanying person

before entering the Hospital
ii. Initial assessment by the triage nurse or the front desk
iii. Implementing infection control precautions when patient is suspected to
have contagious disease
iv. Medical assessment by physician
v. Reporting to facility infection control team and if applicable to
governorate disease surveillance and control department
a. Providing Information and facilities for patients/ accompanying person to

help in containment of infections up on entering to the Hospital:
 Signs are posted in triage areas (e.g., ER entrances) advising patients
with fever and/or symptoms of respiratory infection to immediately notify
triage personnel so appropriate precautions can be put in place.
 On arrival to the ER/OPD, patients/ accompanying person MUST inform
staff if they have any of the following:
1. FEVER with any one or some of the following symptoms:
a. Running nose and body ache
b. Cough
c. Difficulty in breathing
d. Skin rash with or without red eyes
e. Bleeding
f. Profuse diarrhea
g. Headache with or without stiff neck
h. Altered sensorium/consciousness
2. Travelling outside country in the past 4-6 weeks especially in the
context of ongoing outbreak
3. Contact with someone having communicable disease in the past 2-
12 weeks (e.g., COVID-19, Measles, TB)
4. Admission to a hospital in the past 2-12 weeks outside or within the
country.
5. Being diagnosed with any antibiotic resistant pathogens (super bugs)
in the past
 Signs are posted at entrances with instructions to individuals with
symptoms of respiratory infection to:
o Immediately put on a mask and keep it on during their assessment
o Cover their mouth/nose when coughing or sneezing either with paper
tissue or inner elbow and disposal of used tissue paper in the waste
bin.
o Perform hand hygiene after contact with respiratory secretions.
 Facemasks are provided to coughing patients and other symptomatic
individuals upon entry to the facility.
 Alcohol based hand sanitizer and/or hand washing facility for hand
hygiene is available at each entrance to the ER and OPD.
 The Hospital provides tissues and no-touch receptacles for disposal of
tissues in waiting areas.

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 The Hospital has a separate well-ventilated space that allows waiting

patients to be separated by 1-2 meters, with easy access to respiratory
hygiene and cough etiquette supplies.
b. Initial assessment by the triage nurse at ER/OPD:
To minimize transmission of infectious pathogens to healthcare workers,
patients and visitors, check if:
 Patient has history of fever for the past 2 weeks and meets at least ONE
of the following criteria:
o Any respiratory symptoms (cough with or without expectoration,
breathing difficulty)
o Skin rash
o Travel outside the country in the past 4-6 weeks specifically to
endemic areas in the event of an outbreak
o Contact with any person with contagious infectious diseases in the
last 2-12 weeks
o Gastrointestinal symptoms (profuse diarrhea or vomiting) o Bleeding
from any site in the body
 Based on patients symptoms proceed with the next containment
process:
1. Patients with Respiratory symptoms (sneezing, coughing, difficulty
breathing) with or without fever:
This can be any respiratory infection for example; COVID-19, Influenza,
MERS CoV, or even Pulmonary TB but the exposure history can help in
further categorizing them such as:
 Patient who has a family member recently diagnosed with TB
 Patient coming from endemic area with newly emerging respiratory
infection
 Child attending day care during influenza season
** The triage is not the place for making diagnosis rather identify risks, start
containment process and alert staff in ER/OPD to take necessary infection
control precautions to avoid exposure as following:
 The patient should be Instructed to:
o Immediately put on a mask and keep it on during their
assessment
o Cover their mouth/nose when coughing or sneezing either with
paper tissue or inner elbow and disposal of used tissue paper in
the waste bin.
o Perform hand hygiene after contact with respiratory secretions
 Place the patient in a separate well-ventilated space that allows
waiting patients to be separated by 1-2 meters, with easy access to
respiratory hygiene and cough etiquette supplies.
 Ensure patients with confirmed or suspected contagious respiratory
disease (e.g. COVID-19, Influenza, TB) are rapidly moved to an
isolation room. Alternatively, for patients that cannot be immediately
placed in a room for further evaluation, a system is provided that
allows them to wait in a personal vehicle or outside the facility (if

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medically appropriate) and be notified by phone or other remote

methods when it is their turn to be evaluated.
 The health care workers managing the patient should be alerted and
instructed on the need to follow infection control preventive measure:
o Practicing hand hygiene
o Wearing gown, gloves and surgical mask when attending the
patient but if suspect airborne infection or an aerosol generating
procedure, they should put N95 respirator with their correct size
 Infection control team of the facility to be informed about suspect
case based on the facility guideline
 Ensure appropriate environmental cleaning for triage area
2. Patients with fever & rash:
If Patient has fever with maculopapular / pustular/ macular rash with or
without running nose and conjunctivitis, consider the following causes
o Measles o Rubella
o Chicken pox
o Herpes zoster
o Meningococcal infection
o Severe sepsis with DIC
** The triage is not the place for making diagnosis rather identify risks,
start containment process and alert staff in ER/OPD to take necessary
infection control precautions to avoid exposure as following:
 Place the patient immediately in an isolation room with
appropriate isolation sign (airborne and/or contact precaution)
 The health care workers managing the patient should be alerted
and instructed on the need to follow infection control preventive
measures for airborne& contact precautions:
o Practicing hand hygiene as per WHO 5 moments
o Wearing gown, gloves and N95 respirator with their correct
size and seal check
 Ensure appropriate environmental cleaning for triage area
3. Patient with fever & CNS symptoms (headache, altered sensorium,
seizures)
Consider meningitis with/or without sepsis
start containment process and alert staff in ER/OPD to take necessary
infection control precautions to avoid exposure as following:
 Patient to be seated if clinically appropriate and no available isolation
room so that he/she is at least 1-2 meter away from other patients or
visitors.
 Patient will need to be in contact and droplet precautions while
assessed including:
o Isolation room or area with appropriate sign (contact and droplet
precaution)

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o Hand hygiene practices as per WHO 5 moments

o Health care worker attending patient to wear surgical mask,
gloves and gowns
 Ensure appropriate environmental cleaning for triage and isolation
area
4. Patients with fever and gastrointestinal symptoms (vomiting /diarrhea)
 Consider contagious infections like cholera, Clostridium difficile,
rotavirus ---etc.
start containment process and alert staff in A&E, day care, or clinic to
take necessary infection control precautions to avoid exposure as
following:
o Move patient to be in an isolation room or area with contact
precautions and dedicated toilet facility
o Put appropriate sign (contact precaution) at the entrance to the
isolation room or area
o Hand hygiene using water and soap Not alcohol hand sanitizer to
ensure effectiveness against C.difficile and removing soiling as per
WHO 5 moments
o Health care worker attending patient to wear gloves and gowns
o Infection control team of the facility to be informed about suspect
o Ensure appropriate environmental cleaning for triage and isolation
area
5. Patients with fever and bleeding
 Consider contagious hemorrhagic fever or DIC with sepsis
start containment process and alert staff in A&E, day care, or clinic to
take necessary infection control precautions to avoid exposure as
following:
o Place the patient immediately in an isolation room (Preferably
airborne isolation or with mobile HEPA filter) with appropriate
isolation sign (airborne /contact precaution)
o The health care workers managing the patient should be alerted and
instructed on the need to follow infection control preventive
measures of airborne/contact precautions:
 Practicing hand hygiene as per WHO 5 moments
 Wearing gown, gloves and N95 respirator with their correct size
and seal check
 Infection control team of the facility to be informed about suspect
 Ensure appropriate environmental cleaning for triage and
isolation area

Page 18 of 44
6. Patient with risk for MDRO infection and/or colonization

 Consider patient may be carrying or infected with an MDRO if there is
recent history of admission to a health care facility or he/she was
previously diagnosed with MDRO infection/ colonization.
 Move patient to be in an isolation room or area with contact & droplet
precautions
 Put appropriate sign (contact and droplet precaution) at the entrance of
isolation room or area
 Health care worker attending patient should:
o Practice hand hygiene as per WHO 5 moments
o Wear gloves, surgical mask, and gowns
 Infection control team of the facility to be informed about suspect case
based on the facility guideline
 Ensure appropriate environmental cleaning for triage and isolation area
c. Assessment by the Physician in the clinical area of ER/OPD:

 Practice hand hygiene in accordance with the WHO five moments
 Ensure wearing appropriate PPE before entering the isolation room/area
 Gather further history and do clinical assessment for the patient
 Reporting to infection control team and governorate department of diseases
surveillance and control as deemed necessary and in alignment with DOH
guidelines
d. Reporting to facility infection control team and if applicable to governorate disease
surveillance and control department
 In the event of national or international outbreaks of contagious infectious
diseases the triage should include instruction on process of reporting a suspect
case to the facility infection control team and the governorate department of
diseases surveillance and control.
D. Aseptic Technique
1. Objectives:
a. To ensure healthcare workers provide high quality standardized aseptic
practice that conforms to evidence-based practice guidelines.
b. To ensure clinicians understand the principles of Aseptic Technique and
apply them to practice effectively.
c. To provide clinicians with a standardized approach to Aseptic Technique by
which clinicians can be educated, assessed and monitored to ensure
compliance to aseptic technique principles.
2. Process
a. Environmental Control Measures
Prior to conducting a procedure, clinicians should ensure that there are no
avoidable environmental risks nearby. Environmental controls are used to
reduce the risk of contamination by movement, touch or proximity.
Examples of environmental risks may include:
 Bed making
 Cleaning the environment (if in close proximity)
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 Use of commodes by other patients in a shared room

 Movement and proximity of privacy curtain
 Confined working area
 Excessive number of people present
b. Infection Control Measures
1. Hand hygiene:
 Effective hand hygiene is an essential part of AT.
o Routine hand hygiene should be performed using neutral pH
soap and running water (duration of entire wash – 60 seconds) or
an alcohol-based hand rub (duration of entire rub 20 – 30
seconds.
o Surgical hand scrub using an approved antimicrobial skin
cleanser or waterless hand rub formulation is required when full
barrier precautions are necessary.
2. Glove use:
 Non-sterile gloves may be necessary to protect the clinician from
blood or body fluids or exposure to toxic drugs during administration.
 Sterile gloves are required in all surgical aseptic procedures and any
procedures where key parts and / or key sites are touched directly
(i.e. when a non-touch technique cannot be achieved), to minimize
the risk of contamination.
 Selection of sterile or non-sterile gloves is also dependent upon
healthcare worker competency. When preparing for the procedure
healthcare workers should assess their own competence and
experience in performing the procedure and determine whether
touching of key parts or sites is required. If touching may take place
sterile gloves are required.
3. Use of other protective personal equipment (PPE):
 Other PPE should be worn according to standard precautions to
reduce the risk of blood and body fluid exposure to the clinician.
Maximum barrier precautions may be required during invasive
procedures to reduce the risk to the patient of acquiring a healthcare
associated infection during procedures such as CVC insertion.
c. Aseptic field selection and management
1. General aseptic fields that promote asepsis are used when:
 key parts are easily protected by critical micro aseptic fields and non-
touch technique
 the main aseptic field does not have to be managed as a key part
Management of the general aseptic field requires key parts be protected
by Critical Micro Aseptic field (critical micro aseptic fields are those key
parts protected by syringe caps, sheathed needles, covers or
packaging). Asepsis of the immediate procedure environment is
therefore promoted by general aseptic field management.
2. Critical aseptic fields are used when:
 key parts/sites are large or numerous and can’t be easily protected
by covers or caps or can’t be handled with a non-touch technique
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 invasive procedures require a large aseptic working area

Management of the critical aseptic field requires only sterilized
equipment to be placed in the aseptic field; sterile gloves are required to
maintain asepsis.
The aseptic field must be managed to ensure that key parts and key
sites are protected and should be prepared as close as possible to the
time of actual use. Selection of a tray or trolley of an appropriate size will
ensure key parts are adequately contained within the aseptic field.
Trays or trolleys should be cleaned with an appropriate disinfectant wipe
and allowed to dry, before placing any items in or on the tray or trolley.
If a surface remains wet then asepsis will be compromised.
The aseptic field may also need to be extended by draping the patient.
Sterile drapes provide additional work space where sterile equipment
may be placed as well as protecting the key site from contamination.
d. Non-touch technique
Non- touch technique is required at all times to maintain asepsis. Non-touch
technique is a technique where the clinician’s hands do not touch, and
thereby contaminate key parts and key sites. Asepsis can be achieved by
either:
 using a non-touch technique; examples include use of sterile gauze or
sterile forceps
 using sterile gloves
Even when sterile gloves are used, touching of key parts and key sites
should not be touched unless necessary to do so.
e. Waste Management
Waste and sharps must be discarded in the appropriate receptacle.
f. Cleaning of Equipment
On completion of the aseptic procedure and once hand hygiene has been
performed, all equipment used during procedure should be thoroughly
cleaned using detergent and when required followed by a disinfectant.
Cleaning followed by disinfection may be a two step or two in one process.
Ensure all touch surfaces that have been used are cleaned well. Cleaned
equipment should be allowed to dry properly before being put away. On
completion of cleaning hand hygiene should be performed.
3. Practice Guidelines
a. Obtain consent from the patient, check for allergies and complete patient
identification process using three nationally recognized identifiers.
b. Perform risk assessment and manage environmental risks.
c. Perform hand hygiene.
d. Clean the tray/trolley/work surface with detergent and water or detergent
wipe.
e. Identify and gather equipment for procedure. Inspect packaging for
damage; check sterility indicators & expiry dates, ensure any additional
equipment, such as tourniquet, is clean.

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f. Perform hand hygiene (clean hands effectively with soap and water or
ABHR).
g. Prepare critical or general aseptic field.
h. Open procedure pack using corners & drop sterile equipment into sterile
field.
i. Prepare patient – use gloves where appropriate to protect from potential
body fluid exposure.
j. Remove gloves if used.
k. Perform hand hygiene.
Note:
For standard aseptic procedure, clean hands effectively with soap and
water or ABHR.
For surgical aseptic procedure a surgical hand scrub is required.
l. Apply gloves if required.
Note:
If it is necessary to touch key parts or key sites directly, sterile gloves are
used to minimise the risk of contamination. Otherwise, non-sterile gloves
are typically the gloves of choice for standard aseptic procedures.
Sterile gloves are used for all surgical aseptic procedures.
m. Perform procedure ensuring all key parts/components are protected:
 Sterile items are used once and disposed into waste bag
 Only sterile items contact the key site
 Sterile items do not come into contact with non-sterile items
n. Remove gloves (if used) and perform hand hygiene effectively with soap
and water or ABHR.
o. Dispose of all waste (including sharps). Clean equipment and perform hand
hygiene.
4. Monitoring of Performance
Adherence to policy and patient outcomes will be regularly monitored. This will
occur through the use of:
• Monitoring of hospital acquired infections
• Case review of patients with hospital acquired infections and clinical
procedures associated with their care
• Auditing of compliance to aseptic techniques practice guidelines
• Monitoring of clinician training and education in aseptic techniques
• Monitoring of clinician competency in aseptic techniques
5. Responsibility
The Nurse Supervisor is responsible in ensuring nurse’s compliance to policy.
Steps to be taken by Supervisor or delegate if non-compliance is identified
during a healthcare worker’s practice.
 Formal documented assessment of aseptic and non-touch technique
practice.
 Supervision of Healthcare worker’s practice until competence is
demonstrated.
 Notify Infection Control staff.
 Provide further training and education.

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 Re-assess healthcare worker’s practice within one week of providing

education.
E. Cleaning, Disinfection and Sterilization of Medical Devices and Equipment

1. Objectives:
a. To be able to have a standard procedures and policies regarding
disinfection and sterilization.
b. To render safe use of reusable materials and equipment.
a. Decontamination
 It is the physical or chemical process that renders a potentially
contaminated, inanimate object safe for further handling. Contaminated
instruments are soaked in an enzymatic solution for 20 – 30 minutes or
depending on the manufacturer’s instructions.
b. Cleaning
 It is the removal of all adherent visible soil from the surfaces, crevices,
joints, and Lumina of instruments. It could be done through hand
scrubbing, ultrasonic cleaning, and processing with a washer-sterilizer
or washer-decontaminator. Avoid splatter or aerosols generated during
scrubbing by keeping brushes under water during scrubbing.
c. Disinfection
 It is a process that results in the destruction of infectious agents on
inanimate objects but does not necessarily destroy all bacterial
spores. Exposure time and classification of items. (Please refer to Table
on Methods of Fluid Sterilization and Disinfection)
d. Sterilization
 It is a process of complete destruction of any living organism
a. All disinfectant, materials and equipment related to infection control should
have an approval of HICC before purchasing. The product should undergo
the process of evaluation. (Please Refer to Product Evaluation)
b. All used materials and equipment should undergo decontamination prior to
cleaning.
c. All cleaned equipment and instruments are properly sorted according to its
use and undergo appropriate disinfection/sterilization process.
d. Decontamination process
 Use one chemical only, 1% Na hypochlorite is recommended solution
for decontamination. Do not add soap on the solution. Na hypochlorite
is unstable once diluted and should be prepared only when there is
reusable equipment/material for decontamination.
 Place contaminated reusable item in a perforated tray and soak fully
under prepared solution for 30 minutes. Items having lumen should be
filled and no bubbles are observed. Agitate the tray once in a while
during the soaking period to loosen the debris. Rinse and do manual
cleaning.
e. Manual cleaning

Page 23 of 44
 Use soap and water only.

 Wear Personal Protective Equipment (PPE) (i.e. mask, eyewear, gloves,
and gown) during cleaning. If brushing is required to remove debris on
the instrument, brush it under water so that aerosol will not be formed.
 Rinse properly and dry before disinfection or sterilization.
f. Disinfection
 Semi-critical items need high-level disinfection
These are items that come in contact with mucous membranes or
non-intact skin. These medical devices should be free of all
microorganisms, although small number of bacterial spores may be
present. Semi-critical items should be rinsed with sterile water after
high-level disinfection to prevent contamination of microorganism that
may be present in tap water.
 Non-critical items need intermediate low-level disinfection
These are items that come in contact with intact skin but not
mucous membranes. Intact skin acts as effective barrier to most
microorganisms and therefore the sterility of items coming in contact
with intact skin is not critical.
g. Sterilization processes (Cidex)
 Heat sterilization
 Requirement to achieve successful sterilization
MATERIALS FOR
PARAMETERS RANGE DELIVERED
AUTOCLAVING
Wrapped instruments, 1. Sterilizing temp. 134 0C 134 0C
textiles, porous load 2. Sterilizing time 3 – 7 minutes 4 minutes
3. Post vacuum time 0 – 90 minutes 5 minutes
4. Postpuls steam 0 – 90 minutes 0 minute
5. Postpuls air 0 – 90 minutes 0 minute
Heat sensitive material, 1. Sterilizing temp. 121 0C 121 0C
rubber, plastic, porous 2. Sterilizing time 16 – 20 minutes 16 minutes
load 3. Post vacuum time 0 – 90 minutes 5 minutes
4. Postpuls steam 0 – 90 minutes 0 minute
5. Postpuls air 0 – 90 minutes 0 minute
Rapid process for single, 1. Sterilizing temp. 134 0C 134 0C
open instrument 2. Sterilizing time 3 – 90 minutes 4 minutes
Bowie/Dick 1. Sterilizing temp. 134 – 121 0C 134 0C
2. Sterilizing time 0 – 15 minutes 1 minutes
Liquids in open or vented 1. Sterilizing temp. 134 – 105 0C 121 0C
containers 2. Sterilizing time 3 – 90 minutes 20 minutes
Automatic leak test 1. Post vacuum time 5 – 90 minutes 5 minutes
2. Stabilizing time 10 – 90 minutes 10 minutes
3. Test time 10 minutes

Page 24 of 44
h. Monitoring sterilization process

1. Physical monitoring
 observe and record the parameters of sterilizer functioning
such as time, temperature, pressure or gas concentration;
2. Chemical monitoring
 color or physical-change indicators that detect exposure to sterilizing
agents or conditions;
 Assures that product is not mistaken for that which has been
sterilized
 Ensures proper packing and sterilizer load configurations
 Ensures the proper functioning of the processing equipment.
3. Biologic monitoring
 spore testing, the most important check on sterilizer function.
4. For steam sterilizer, biological indicator (BI) should be placed at the front
on the bottom and near the door in a routinely loaded sterilizer;
5. For EO sterilizer, BI should be in the center of the load or see
manufacturers’ recommendation.
6. If a sterilizer underwent preventive maintenance or repair, challenge the
unit to confirm proper operation. The unit should be operated until two
consecutive runs return negative BI results before the unit is returned
fully to service.
i. Storage
 The storage area should be adjacent to sterilizing area, preferably in a
separate enclosed, limited access and well ventilated area to provide
protection against dust, moisture, and temperature and humidity
extremes.
 The area should be free of insect or vermin that seek the warmth of
reprocessed packages for habitat.
 Sterile materials should be stored at least 8 to 10 inches from the floor,
at least 18 inches from the ceiling and at least 2 inches from outside
walls.
 Items should be positioned so that packaging is not crushed, bent,
compressed or punctured.
 Avoid placing sterile supplies on the floor or near window sills.
 All sterilized package within the facility should be labeled with load
control number that indicates the sterilizer used, cycle or load number,
the date of sterilization, and an expiry date. Expiry date for woven linen
pouch is one (1) week and fifty (50) weeks for polypropylene peel
pouches.
 Stock sterile packages on a first in first out stock piling according to
process dates to avoid unnecessary reprocessing.

Page 25 of 44
j. Distribution of sterile goods

 Packs transported to operating rooms and other areas within the
healthcare facility should be provided with an additional outer dust-
protection cover that can be removed before the pack is taken into the
clean zone. This is also applied either to individual packages or to the
total cart. Transport vehicle should be exclusive for use.
k. Maintenance of sterilizer
 Preventive maintenance of all sterilizing equipment should be every 3
months using the manufacturer’s service manual as reference.
 Sterilizers should be cleaned daily or as per manufacturer’s
recommendation to prevent accumulation of residue that may transfer
on the packaging during sterilization process.
 The time-temperature charting devices and temperature-pressure
gauges should be calibrated after any repair and at least every 6 months
or at the interval recommended by the sterilizer manufacturer.
l. Environmental Control
1. SINKS
 It should be decontaminated with sodium hypochlorite every shift
after scrubbing with soap and water.
 There should be separate sink for washing dirty items.
 There should be another sink for the clean or previously soaked
items.
2. FLOORS
 mopping and sweeping of floors should be done before operation
and or as necessary. There should be a separate mop and broom
for exclusive use in the area.
3. WALLS
 clean at once when grossly soiled by scrubbing with soap and water.
Once a month scrubbing with soap and water followed by Na
hypochlorite disinfectant.
F. Environmental Cleaning and Disinfection

1. General Principles and Strategies
a. Select hospital registered disinfectants, and use them in accordance with
the manufacturer’s instructions.
b. Do not use high-level disinfectants/liquid chemical sterilants for disinfection
of any environmental surfaces
c. Keep housekeeping surfaces (e.g., floors, walls, and tabletops) visibly clean
on a regular basis and clean up spills promptly.
 Clean and disinfect the environment in patient-care areas when
uncertainty exists regarding:
o the nature of the soil on these surfaces [e.g., blood or body fluid
contamination versus routine dust or dirt
o the presence or absence of multi-drug resistant organisms on such
surfaces. •

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 Detergent and water are adequate for cleaning surfaces in

nonpatientcare areas (e.g., administrative offices).
 Clean and disinfect high-touch surfaces (e.g., doorknobs, bed rails, light
switches, and surfaces in and around toilets in patients’ rooms) on a
more frequent schedule than minimal touch housekeeping surfaces.
 Avoid large-surface cleaning methods that produce mists or aerosols or
disperse dust in patient-care areas.
d. Follow proper procedures for effective use of mops, towels, and solutions.
 Prepare cleaning solutions daily or as needed, and replace with fresh
solution frequently according DOH protocols.
 Change the mop head at the beginning of the day and also as
required by local policy, or after cleaning up large spills of blood or
other body substances.
 lean mops after use and allow to dry before reuse (e.g., launder and
dry at least daily) or use single-use, disposable mop heads.
e. When performing low- or intermediate-level disinfection of environmental
surfaces in nurseries and neonatal units, avoid unnecessary exposure of
neonates to disinfectant residues on environmental surfaces by using a
registered disinfectants in accordance with manufacturers’ instructions and
safety advisories.
2. Cleaning Schedule
a. Cleaning schedule should be based on the following:
 The location within the facility.
 Type of surface to be cleaned.
 Type of soil present.
 Tasks or procedures being performed. This may be achieved by
classifying areas into one of four functional areas.
b. Functional Areas
i. Very high-risk area
 In very high-risk functional areas cleaning standards require the
highest level of intensity and frequency of cleaning.
ii. High risk area
 Cleaning standards in high-risk areas are maintained by frequent
scheduled cleaning and a capacity to “spot” clean.
iii. Moderate risk area
 Cleaning standards in moderate risk areas are important for both
hygiene and aesthetic reasons and are maintained by routine
scheduled cleaning with some capacity to spot clean in between.
iv. Low/minimal risk area
 Cleaning standards in low-risk areas are important for aesthetics
and, to a lesser extent, hygiene and are maintained by cleaning on
a routine basis with capacity to spot clean in between scheduled
cleaning.
*** In the event of an outbreak of a transmissible disease or infection, eg
gastroenteritis or a multi-resistant organism, the affected ward should be re-
categorized from moderate risk to very high risk for the period of the outbreak.
Page 27 of 44
3. Cleaning Method
a. Wet cleaning is recommended and drying is essential.
b. High dusting: All surfaces above shoulder height should be dusted with a
damp mop to prevent dust from being dispersed.
 Mops must never be shaken.
 To prevent missing spots, work should proceed either clockwise or anti
clockwise from the starting point.
 While high dusting, observe for possible leaks in pipes; since it may
provide a reservoir for fungal growths. If found, report for immediate
repair.
c. Walls, windows and doors including door handles should be spot cleaned
when needed and cleaned completely on regular schedule daily.
d. Periodically change and launder windows' curtains in clinical/ward areas
every 3 months. Change and launder if visibly soiled or splashed with body
fluid or after discharge of isolated patient with MRSA, Group A Strep,
Clostridium difficile or following a viral gastroenteritis outbreak.
e. For cubicle curtains, launder weekly and after patient discharge. Change
and launder immediately if splashed with body fluid
f. Horizontal surfaces including tables, beds, chairs, should be wiped with a
clean cloth dampened with disinfectant in high and very high-risk areas.
g. Bathrooms should be cleaned daily, with special attention to toilet.
4. Cleaning Frequency
a. In patient rooms
 High dusting; spot cleaning of walls, windows, and doors, light fixtures,
chairs , beds and floors should be performed daily and when the patient
is discharged.
 The same daily cleaning with disinfection should be done for rooms of
patients on isolation precautions.
 High touch surfaces (e.g., door knobs, bed rails, light switches should
be cleaned and disinfected on a more frequent schedule.
 When the infected patient is taken off isolation precaution or discharged,
clean equipment should be used to provide thorough terminal cleaning.
b. Procedure rooms and delivery room:
 Cleaning of horizontal surfaces, equipment, and furniture used for the
procedure is necessary after each patient.
 Procedure room should be cleaned with a detergent solution followed by
disinfection as needed after each patient and at least daily.
 In delivery room, end-of-case cleaning is only necessary to clean 1.5
meter perimeter around the operative site; the cleaning area should be
extended if greater contamination has occurred.
 After the last delivery of the day or night, disinfect delivery room floors
with a registered hospital disinfectant.
 Do not use mats with tacky surfaces at the entrance to delivery rooms.
 A clean mop head should be used for each case.

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 For terminal daily cleaning, all the equipment on the floor should be
removed to allow cleaning of the entire floor area.
5. Cleaning Supplies/Equipment
a. Buckets
 Trolley with double separate buckets should be provided. Blue bucket
for cleaning solution mixed with water and other red bucket for rinsing
water.
 Water should be changed in between cleaning of:
o General rooms.
o Corridors.
o Private room.
o Treatment room, dressing room, store and linen room.
 Separate buckets should be provided for the cleaning of bathrooms and
each isolation rooms.
 After cleaning, buckets should be emptied, cleaned and kept dry.
b. Mops
 Enough mops with long handles should be provided for each location
within the healthcare facility.
 Dedicate separate mops for corridors, general rooms, private rooms,
treatment, dressing, store and linen room, bathrooms and isolation room
and an extra mop in case of spillage of blood and body fluids.
 Outpatient and causality should be provided with enough number of
mops according to the number of rooms.
 These mops should be detached and laundered and dried every shift
c. Towels
 Used to clean the surfaces.
 Color coding should be followed:
o Yellow for infectious materials and infected surfaces.
o Red for bathrooms
o Blue for general purpose.
d. Personal protective equipment
 Gloves should be worn when performing any cleaning activity.
 In most situations, disposable gloves are preferable.
 Heavy duty gloves are recommended if the task has a high risk for
percutaneous injury.
 When there is a potential for splashing or splattering, a fluid-resistant
gown or apron, protective eyewear, and mask should be worn.
6. Disinfectants Used for the Environment in the Hospital
a. Chlorine and chlorine compounds
 It is fast acting and has a broad spectrum of antimicrobial activity.
 It is active against viruses. It is the disinfectant of choice for
decontamination of blood and body fluids. (500 ppm for small spills-5000
ppm for large spills).
 It can be used for disinfection of hard surfaces.e.g., sinks and baths.
 Diluted solutions are unstable and should be freshly prepared daily.

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 It is incompatible with cationic detergents.

b. Alcohols
 Alcohols in the concentrations of 70-90% can be used for disinfection of
some hard surfaces but should be used only on physically clean
surfaces.
c. Phenolics
 Used for cleaning walls, floor and furnishings.
 Can be used for cleaning hard surfaces
 A phenolic must not be used in the nursery on surfaces (e.g., bassinets,)
that may come in contact with infants. There is an association between
the excessive use of a phenolic disinfectant and hyperbilirubinemia in
newborns.
7. Ineffective Practices
 Fumigation with formalin is an ineffective method of reducing the risk of
infection. It is toxic and irritant to the eyes and mucous membranes, in
addition to being time consuming and makes rooms unavailable for use.
8. Cleaning Spills of Blood and Body Fluids
a. Procedures for dealing with small spillages eg, splashes and droplets
(<10mL)
 Gloves and a plastic apron must be worn
 The area should be wiped thoroughly using disposable paper roll /
towels.
 The areas should be cleaned using a neutral detergent and warm water.
 Use a 1:100 dilution of a 5.25-6.15% sodium hypochlorite provides
which provides 525-615 ppm available chlorine to decontaminate
nonporous surfaces after a small spill.
 The gloves, apron and paper roll / towels should be put into a clinical
waste bag.
 Wash hands.
b. Procedure for dealing with large spills (>10 ml):
1. Large blood spills in a 'wet' area e.g., a bathroom or toilet area:
 Where large spills have occurred in a ‘wet’ area, such as a bathroom
or toilet area, the spill should be carefully washed off into the
sewerage system using copious amounts of water and the area
flushed with warm water and detergent.
 The area must then be disinfected using a chlorine releasing agent.
Use a 1:100 dilution (e.g., 1:100 dilution of a 5.25-6.15% sodium
hypochlorite provides 525- 615 ppm available chlorine)
2. Large blood spills in 'dry' areas (such as clinical areas)
 Where possible, isolate spill area
 Where a spillage of potentially infectious material has occurred, the
area must be vacated for at least 30 minutes for aerosol particles to
be dispersed.
 Wear disposable cleaning gloves, eyewear, mask and plastic apron
 Cover the spill with paper towels or absorbent granules, depending
on the size of the spill, to absorb the bulk of the blood or body
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fluid/substance. Use disposable (for example, cardboard) scraper

and pan to scoop up absorbent, paper towel and any unabsorbed
blood or body substances
 Place all contaminated items into yellow plastic bag or in sharp
container for disposal.
 Pour 5,000 ppm chlorine solution and allow 10 minutes to react then
wipe up making sure that you don’t allow it to come into contact with
your skin or clothing and discard in biohazard waste.
 Decontaminated areas should then be cleaned thoroughly with warm
water and neutral detergent.
 Follow this decontamination process with a terminal disinfection. Use
a 1:100 dilution (500–615 ppm available chlorine)
 Discard contaminated materials (absorbent toweling, cleaning
cloths, disposable gloves and plastic apron).
 Wash hands
 Clean and disinfect bucket and mop. Dry and store appropriately.
c. Procedure for dealing with spilled Urine, feces, sputum and vomit:
 single use gloves and a plastic apron must be worn.
 The spillage should be covered with disposable paper towel to absorb
the spilled material. These should then be gathered up and placed in a
yellow waste bag. The area must then be cleaned thoroughly using
detergent and hot water and dried.
 The area must then be disinfected using a chlorine releasing agent. Use
a 1:100 dilution (e.g., 1:100 dilution of a 5.25-6.15% sodium hypochlorite
provides 525-615 ppm available chlorine)
 Protective clothing and paper must be discarded into the yellow waste
sack.
 Wash hands.
G. Health Care Waste Management

1. Objective
 To provide safe, efficient and environment-friendly management of waste
generated on all work areas from segregation, collection, handling,
transport, storing and treatment until disposal.
a. Health Care Waste - includes all wastes that is generated or produced as a
result of any of the following:
 Diagnosis, treatment, or immunization of human beings or animals;
 Research pertaining to the above activities;
 Production or testing of biologicals; and
 Waste originating from minor or scattered sources.
b. Categories of Health Care Waste
i. General Waste
 Comparable to domestic waste, this type of waste does not pose
special handling problem or hazard to human health or to the
environment. It comes mostly from the administrative and

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housekeeping functions of health care premises. General wastes are

disposed to the city waste disposal system.
ii. Infectious Waste
 This type of waste is suspected to contain pathogens (bacteria,
viruses, parasites, fungi) in sufficient concentration or quantity to
cause disease in susceptible host. This includes:
o Cultures and stocks of infectious agents from laboratory work;
o Waste from surgery autopsies on patients with infectious
diseases (tissues, materials or equipment that have been in
contact with blood and other body fluids);
o Waste from infected patients in isolation areas (excreta,
dressings from infected surgical wounds, clothes heavily soiled
with human or other body fluids);
o Waste that have been in contact with infected patients
undergoing hemodialysis (dialysis equipment and used PPEs);
o Infected animals from laboratories; and
o Any other instruments or materials that have been in contact with
infected persons or animals.
iii. Pathologic Waste
 consists of tissues, organs, body parts, human fetus and animal
carcasses, blood and body fluids. Within this category, recognizable
human or animal body parts are also called anatomical waste and
considered infectious waste, even though it may also include healthy
body parts.
iv. Sharps
 It includes needles, syringes, scalpels, saws, blades, broken glass,
infusion sets, knives, nails and any other items that can cause a cut
or punctured wounds. Whether or not they are infected, such items
are usually considered as highly hazardous health care waste.
v. Pharmaceutical Waste
 It includes expired, unused, spilt, and contaminated pharmaceutical
products, drugs, vaccines, and sera that are no longer required and
need to be disposed of appropriately. This category also includes
discarded items used in handling of pharmaceuticals such as bottles
or boxes with residues, gloves, mask, connecting tubing and drug
vials.
vi. Genotoxic Waste
 It includes certain cytotoxic drugs, vomit, urine, or feces from patients
treated with cytotoxic drugs, chemicals, and radioactive materials.
This type of waste is highly hazardous and may have mutagenic,
teratogenic, or carcinogenic properties.
 Contaminated materials from drug preparation and administration
(needles, syringes, gauge, vials, packaging; outdated drugs,
excess/leftover solutions, and drugs returned from the wards.
 Urine, feces, and vomit from patients which may contain potentially
hazardous amounts of administered cytotoxic drugs or of their

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metabolites and which should be considered genotoxic for at least

48 hours and sometimes up to 1 week after drug administration.
vii. Chemical Waste
 It consists of discarded solid, liquid, and gaseous chemicals from
cleaning, housekeeping, and disinfecting procedures. Chemical
waste maybe hazardous or non-hazardous.
 Waste with high content of heavy metals – mercury, cadmium
 Pressurized Containers
 Radioactive Waste
c. Composition of Health Care Waste
Health care waste from other sources generally has the following
composition:
 Health care provided by nurses
o General waste, a limited amount of infectious and some sharps
 Physicians’ offices/clinics
o General waste, a limited amount of infectious and some sharps
1. Medical Wards
 Mostly general waste; a limited amount of infectious waste such as
blood-soaked dressings, bandages, and sticking plaster;
contaminated gloves, contaminated packaging and disposable
medical items; used or unused hypodermic needles and IV sets; and
certain body fluids.
2. Emergency Room, OPD, Delivery Room
 General waste (including packaging); pathological and anatomical
waste, including tissues, organs, products of conception and body
parts other potentially infectious wastes (blood soaked gauze and
materials, contaminated gloves, tubing, body fluid containers, and
sharps).
3. Other Health Care Units
 Mostly general waste with small percentage of infectious waste
(mostly sharps)
4. Laboratory
 General waste (including packaging and containers), pathological
(including some anatomical) wastes, tissue samples, microbiological
cultures and stocks, blood and body fluids, contaminated gloves,
tubing and containers, sharps, possibly some radioactive materials,
a large number of chemicals. Tissue samples are packed with
formalin and no longer infectious but must be separated creating a
chemical and a pathological waste for proper disposal.
5. Pharmacy
 Mainly general waste, product packaging, small quantities of
pharmaceutical and chemical waste (if stocks are properly managed
to prevent large quantities from expiring), possibly cytotoxic drugs, if
chemotherapy treatment are prepared in the pharmacy.

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6. Support units
 General waste
d. Waste Segregation Guide:
 Black
 Green
 Yellow
 Sharp Containers
 Yellow with black band
 Orange
e. Policy Guidelines
 The waste water should undergo treatment (primary, secondary, tertiary,
and sludge treatments) prior to disposal to the nearest body of water.
 Liquid medical wastes are disposed on the designated sinks on every
patient floor.
 The hospital solid wastes should be segregated according to the
prescribed color coding of waste bins lining as follows:
o Black for dry non-infectious waste
o Green for wet non-infectious waste
o Yellow for wet and dry waste contaminated with blood and body
fluids
o Yellow with black band for hazardous materials
o Orange for waste generated from radiation rooms
o Sharp Containers for items that can cause cuts or puncture wounds
(i.e. scalpels, syringes etc.)
 All patient care areas should be provided with color coded waste bins.
 Everybody in the hospital is responsible for proper segregation of
generated wastes.
 The housekeeper is responsible for collection and transport of
segregated waste on a regular basis. Appropriate PPE should be used.
 Tong should be used to collect unidentified waste to avoid sharp injuries.
 Used close thoracostomy tube (CTT) bottles and suction bottles should
be decontaminated prior to disposal of contents.
 General wastes are disposed to the city waste disposal system.
 All other wastes are disposed to outsourced contractors.
 Body parts may not be included in the disposal of pathologic waste.
SEGREGATION OF HEALTHCARE WASTE ACCORDING TO TYPES OF WASTE

AND SOURCES
WASTE SEGREGATION
EXAMPLES OF WASTE
GUIDE

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Needles and syringes

Scalpel blades
Glass vials – tuberculin/insulin
Stylet
Capillary tubes
Ampules
Test tubes
RED (Sharps and Pressurized
Blood evacuation tubes
Containers)
Pipette slides/cover slips
Aluminum cover
Blood lancets
Empty aerosol cans
Rusty pins, nails, clips, and
screws
Broken glasses
Gauze, cotton bandage, cotton
applicators soaked with
blood/body fluids from dressing
of infected wounds and post
operative cases, procedures
such as PAP Smear,
immunization
Foreign bodies removed from
any body parts
Placenta, umbilical cord
Used gloves
Used Foley catheters
Used tubing – IV, nebulizer
Used diapers, sanitary napkins
Used suction tubes
YELLOW (Infectious and
Used NGT
Pathological Wastes)
Used test drips
Used urine bags
Used drains – penrose
Used cord clamp
Used plaster
Empty colostomy bag
Used swabs
Heplock
Endotracheal tubes
Used tongue guard
Used oxygen tubing
Used glad wrap
Used mask/face mask
Used thoracic tube
Used hemovac

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Used sensor/electrodes
Used bandages
Used rubber sheet
Used rubber tubing
Used CVP tubes
Used t-tubes
Used central lines
Used oxygen catheter
Amputated limbs, toes, fingers,
organs, extracted tooth
Tissues from minor/major
operation
Specimen containers of blood
and body fluids
YELLOW (Infectious and Used culture media, tissue
Pathological Wastes) culture plate
Used beads/plates
Used kit from laboratory
analyzer
Used reaction pads, foils
Used plastic wares/disposable
Used tissue typing/x-matching
trays for discards
Used filters
Used blood product bags and
tubing
Empty bottles of acids, HCl,
H2SO4, HNO3, etc
Empty bottles of betadine,
iodine, KMNO3
Empty bottles of laboratory
reagents (Formaline, Tolouene,
Xylene)
Empty bottles/cans of Kerosene,
YELLOW (Chemical and Acetone, Alcohol, Anesthetic
Pharmaceutical Wastes) lacquer
Empty bottles of disinfectants
Busted fluorescent bulb
Defective thermometer
Empty cans of glue, epoxy, and
floor wax
Expired and adulterated drugs
and medicines
Used batteries
BLACK (Non-infectious Dry Paper and paper products
Wastes)  Used papers

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Newspapers
Tetra packs, paper cups
Boxes/cartons
Bottles
Glass and plastic
Packaging materials
Styropore
Aluminum
Plastic, candy/food wrapper
Kitchen left-over food
Used cooking oil
GREEN (Non-infectious Wet Fish entrails, scale, and fins
Wastes) Fruits and vegetables peelings
Rotten fruits and vegetables
Non-infection left over foods
1125 (Iodine 125)
Iodine 131
Things contaminated with these
radioactive materials
Gloves
ORANGE (Radioactive/Nuclear Tissue papers
Wastes) Cotton swabs
Aluminum foil
Gauze
Test tubes
Pipette tips
Repetitive syringes
H. Safe Injection Practices

1. Objective
 To prevent the spread of blood borne pathogens and bacterial infections
through the use of safe injection practices and ongoing standardized
competency training.
2. Policy
 All members of the healthcare team will follow best practices guidance from
researches and evidence-based practices regarding the safe use of
needles, syringes, medications, cannulas and intravenous delivery
systems.
3. Procedures
a. Scrub the cap or port of invasive lines with alcohol using friction before
injecting an IV medication.
b. Use a sterile, single-use disposable needle and syringe for each injection
given.
c. Do not administer medications from a syringe to multiple patients, even if
the needle or cannula on the syringe is changed.

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d. Use fluid infusion and administration sets (i.e., intravenous bags, tubing and
connectors) for one patient only and discard appropriately after use.
Consider a syringe or needle/cannula contaminated once used to enter or
connect to a patient’s intravenous infusion bag or administration set.
e. Use single-dose vials for parenteral medications whenever possible.
f. Do not administer medications from single-dose vials or ampules to multiple
patients or combine leftover contents for later use.
g. If multidose vials (MDV) must be used, both the needle or cannula and
syringe used to access the MDV must be sterile.
 Date and time every MDV
 Check date and time every time you use a MDV to ensure it is in-date.
h. Before each withdrawal from a MDV, scrub the surface of the rubber
diaphragm with alcohol using friction.
i. Do not keep MDV in the immediate patient treatment area; store MDV
according to the manufacturer’s recommendations; discard if sterility is
compromised or questionable.
I. ISOLATION POLICY
1. Objectives
 To prevent exposure to infectious communicable diseases among
healthcare workers and patients
 To properly contain the spread of infectious communicable diseases among
patients
a. Airborne stan is indirect method of transfer. Entities transmitted by this
method include droplet nuclei 1 – 5μm and remain suspended on air for
long periods, spores, and shed microorganisms. They are Mycobacterium
Tuberculosis, chicken pox, and measles.
b. Droplet transmission is a direct transfer of large particle droplet spread of
infectious secretions within 3 feet distance through talking, coughing,
sneezing or performance of procedures.
c. Contact transmission is a transfer of microorganisms through direct contact
(e.g. touching) or contact with contaminated items in the environment.
a. Hand hygiene is a MUST (Please Refer to Hand Hygiene Guidelines)
b. Standard precaution should be applied to all patients during triaging until
diagnosed.
c. The personal protective equipment (PPE) to be used is gloves, mask, eye
shield, and gown. (Please Refer to Personal Protective Equipment)
d. Transmission-based precaution should be applied to all patients in addition
to standard precaution once diagnosed. The modes of transmission are
Droplet, Airborne, and Contact.
e. The Personal Protective Equipment (PPE) for Droplet precaution in addition
to standard precaution is the use of mask.

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f. The Personal Protective Equipment (PPE) for airborne precaution in

addition to standard precaution is the use N95 mask.
g. The Personal Protective (PPE) for Contact precaution in addition to
standard precaution is the use gloves and gown.
h. All contaminated items and patient care equipment should undergo the
process of decontamination, cleaning and disinfection/sterilization.
i. Place a color-coded tag at the door entrance under the doctors’ name on
the appropriate isolation practices to apply.
j. Ward is used for cohorting of patients. There should be three (3) feet
distance in between patients. Patients with airborne infection should not be
admitted in the ward.
k. Always refer to the attached list of diseases, type of precaution, and room
placement. This is your guide to carry isolation practices properly.
l. Use of appropriate Personal Protective Equipment (PPE) as precautions in
order not to be exposed to communicable diseases both for healthcare
workers and patients. (Please Refer to Table for Appropriate Use of
Personal Protective Equipment)
m. Standard Precaution on blood and body fluids for unknown cases
 Hand hygiene
 Use of gloves (sterile or non-sterile)
 Use of mask (N95 or surgical mask)
 Use of protective eyewear
 Use of gown (water resistant or linen gown)
n. Transmission-based Precaution after proper diagnosis
 Airborne precaution
 Droplet precaution
 Contact precaution
 Protective environment
APPROPRIATE USE OF PERSONAL PROTECTIVE EQUIPMENT (PPE)
Single Room Mask Gloves Gown Patient

Transport
Standard + or - + or - + or - + or -
Precautions
Droplet + or - + (if within + (if soiling + + mask
(but 3 ft. 3 ft from is likely) (if soiling (ordinary
distance bet. the is likely) surgical
beds) patient) mask)
Airborne + (door is + + (if soiling + (if + mask

always (preferabl is likely) soiling is (pref N95)
closed); y N95 likely)
negative - mask)
pressure

Page 39 of 44
Contact - - + + (if + gown

soiling is and
likely) gloves

Page 40 of 44
Annex A
DUTIES AND RESPONSIBILITIES OF IPC UNIT MEMBERS
POSITION : UNIT HEAD

REPORTS TO : CHIEF OF HOSPITAL
SUPERVISES : INFECTION CONTROL TEAM AND ACTIVITIES
GENERAL DUTIES AND RESPONSIBILITIES :

 Plans, organizes, directs and controls all activities of the departments.
SPECIFIC DUTIES
 Takes a lead role in the effective functioning of the infection prevention and control
team.
 Assists the hospital in drawing up annual plans, policies and long-term programs
for the prevention of hospital infection.
 Recommends in the preparation of the documents for support services and
advises on infection aspects.
 Gets involved in setting quality standards with regards to prevention of healthcare
associated infections and in the audit of infections.
QUALIFICATIONS
 Preferably a doctor with Infection Control Training certified by Philippine Hospital
Infection Control Society.
POSITION : INFECTION PREVENTION AND CONTROL NURSE

REPORTS TO : IPC UNIT HEAD
SUPERVISES : ALL NURSING STAFF, AND HEALTH CARE WORKERS
GENERAL DUTIES AND RESPONSIBILITIES:

 Coordinates and supervises all activities in the hospital relevant to infection control.
SPECIFIC DUTIES
 Acts as coordinator to all hospital staff relevant to infection control. • Identifies
healthcare associated infections.
 Investigates type of infection and infecting organisms. • Participates in outbreak
investigation.
 Participates in analyzing trends and risk factors.
 Conducts surveillance of hospital infections.
 Participates in training of personnel.
 Assists in the development of infection control policies and strategies, reviews and
approves patient care policies relevant to infection control
 Ensures compliance with local and national regulations.
 Serves a liaison with other departments of the hospital.
 Provides expert consultative advice to staff health and other appropriate hospital
programs in matters relating to transmission of infections.
 Attends professional meetings and conferences on matters related to infection
control.

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 Regularly monitors infection control practices and compliance of healthcare

workers.
 Monitors staff health in collaboration with the Employees Health Services
Department to prevent hospital related infection among hospital staff.
 Participates in sharp injuries investigation and prevention activities.
 Serves as a preceptor in nursing training programs.
 Conducts research studies relevant to infection control.
QUALIFICATIONS
 or at least a nurse supervisor with clinical and administrative expertise.
 Good interpersonal and educational background.
 Good communication skills
 With Basic Training in Infection Prevention and Control certified by Philippine
Hospital Infection Control Nurses Association.
POSITION : MEDICAL TECHNOLOGIST

REPORTS TO : IPC COORDINATOR AND IPC TEAM
SUPERVISES : LABORATORY STAFF
GENERAL DUTIES AND RESPONSIBILITIES

 Coordinates and implements the safe delivery and handling of laboratory
procedures.
SPECIFIC DUTIES
 Handles patient and staff specimens to maximize the likelihood of microbiological
diagnosis.
 Develops guidelines for appropriate collection, transport and handling of
specimens.
 Ensures laboratory practices meet appropriate standards.
 Ensures safe laboratory practice to prevent infection among staff.
 Performs antimicrobial susceptibility testing following internationally recognized
methods and prevailing summary reports of prevalence of resistance.
 Monitors sterilization, disinfection and the environment where necessary
laboratory activities take place.
 Communicates the results to the infection prevention and control unit.
QUALIFICATIONS
 Licensed microbiologist or medical technologist trained in microbiology.
 With 2-year experience
 Good communication skills
 With teaching ability
 With infection control training certified by Philippines Hospital Infection Control
Society.

Page 42 of 44
POSITION : ADMINISTRATIVE OFFICE REPRESENTATIVE

REPORTS : CHIEF OF HOSPITAL
SUPERVISES : ALL EMPLOYEES

 Acts as liaison between IPC Unit and administration, implements and executes
policies.
SPECIFIC DUTIES
 Facilitates dissemination and implementation of IPC Unit recommendations and
policies.
 Ensures financial support for the infection prevention and control program.
 Identifies appropriate resources of programs to monitor infections and apply the
most appropriate methods for preventing infections.
 Ensures education and training of all staff through support of programs on the
prevention of infection disinfection and sterilization techniques, etc.
 Ensures that the infection prevention control team has authority to facilitate
program functions.
QUALIFICATIONS
 Senior member of administrative office
 With special interest on infection control
POSITION : NURSING REPRESENTATIVE (LINK HEAD NURSE)

REPORTS TO : IPC UNIT
SUPERVISES : NURSING STAFF AND NURSING AIDES/ORDERLIES

 Conveys to nursing staff the recommendations of IPC Unit for hospital-wide
implementation.
 Participates in IPC Unit activities.
 Promotes the development and implementation of nursing techniques and ongoing
review of aseptic nursing policies, with approval of the IPC Unit.
 Develops training programs for members of nursing staff.
 Supervises the implementation of techniques for the prevention of infection in
specialized areas such as the operating room, adult and pediatric intensive care
unit, maternity unit and newborn unit.
 Monitors nurses' adherence to policies.
 Ensures nurse education programs that include IPC policies and procedures.
 Limits patient exposure to infections form visitors, hospital staff, other patients or
equipment used in the diagnosis or treatment.
 Maintains hygiene consistent with hospital policies and good nursing practice in
the ward.
 Report promptly to the attending physician any evidence of infection in the patients
under nurse’s care.

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QUALIFICATIONS
 Registered Nurse
 With supervisory position
 With basic IPC training certified by IPC Unit.
 Able to train
POSITION : PHARMACIST
SUPERVISES : PHARMACISTS

 Coordinates with the IPC Unit on matters related to IPC.
SPECIFIC DUTIES
 Obtains, stores and distributes pharmaceutical preparation using practices which
limit potential transmission of infectious agents to patients.
 Dispenses anti-infectious drugs and maintains relevant records (potency,
incompatibility, conditions of storage and deterioration.
 Obtains and stores vaccines making them available as appropriate.
 Provides the AMS Committee and IPC Unit with summary reports and trends of
antimicrobial use.
 Participates in the development of guidelines for antiseptics, disinfectants and
products used for hand hygiene.
 Communicates with IPC Unit and Nursing Services the Pharmacy Services
maintenance and other appropriate services.
 Advises the staff on appropriate indications for disinfectants, antiseptics and
antibiotics.
 Keeps record of cost and usage of antibiotics and disinfectants.
 Coordinates with IPC Unit on evaluation of disinfectants, antiseptics and antibiotics
and other new products with IPC implication.
QUALIFICATIONS
 Registered pharmacist
 With basic IPC and AMS training
POSITION : ENGINEERING OR MAINTENANCE REPRESENTATIVE

SUPERVISES : ENGINEERING OR MAINTENANCE STAFF

 Maintains and controls hospital and IPC related equipment and facilities.
SPECIFIC DUTIES
 Tests and maintains efficiency of equipment within the IPC requirements.
 Monitors and maintains the water and electricity supplies.
 Installs and repairs existing equipment to meet required IPC standards.
 Practices standard precautions during performance of duties.

Page 44 of 44
Collaborates with other departments in selecting equipment and ensuring early

identification and prompt correction of any defect.
 Performs preventive maintenance of equipment at prescribed intervals.
 Inspects all surfaces, walls, floors, ceilings and other areas in the facilities
regularly to ensure they are smooth and washable.
 Ensures regular measurement of air changes per hour of specific areas in the
facility and reports measurement to IPC Unit/Committee
QUALIFICATIONS
 With training on IPC equipment maintenance and basic IPC
POSITION : HOUSEKEEPING REPRESENTATIVE

SUPERVISES : HOUSEKEEPERS

 Maintains the environment clean and safe.
SPECIFIC DUTIES
• Maintains and monitors hospital-wide cleanliness and sanitation.
• Coordinates with the IPC Team on proper waste disposal and use of disinfectants.
• Monitors housekeeping practices with IPC implications.
• Implements cleaning and disinfection policies in the workplace.
• Observes and practices IPC precautions of housekeepers during work.
• Classifies different areas of the hospital based on varying needs for cleaning.
• Develops policies on cleaning and disinfection techniques.
• Informs the engineering or maintenance services on any building problems
requiring repair.
• Maintains pest control in the hospital.
QUALIFICATIONS
 College graduate with experience in supervising healthcare facilities housekeeping

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Republic of the Philippines

Province of Ilocos Norte

PHIC ACCREDITED HEALTH CARE PROVIDER

TITLE OF DOCUMENT: POLICY, GUIDELINES AND STANDARD

CATEGORY: INFECTION CONTROL

AUTHOR: MARK EMIL U. BAUTISTA

NOTED BY: ROGELIO BALBAG, M.D.

APPROVED BY: Hon. MATTHEW J. MARCOS MANOTOC

EFFECTIVITY: UPON APPROVAL

Healthcare-associated infection (HCAI) is one of the most common complications

II. Management Structure

A. Responsibilities of the Chief of Hospital

B. Infection Control and Prevention Unit

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 Ensures adequate, accurate and timely reporting and feedback of

C. Members of the Infection Prevention and Control Unit

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D. Infection Prevention and Control Committee (IPCC)

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III. Guidelines, Policies and Standard Operating Procedures

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 When alcohol-based hand is already used, do not use antimicrobial soap

c. Surgical Hand Preparation

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 When using an alcohol-based product, use sufficient product to keep hands

d. Selection and Handling of Hand-Hygiene Agents

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f. Fingernails of Healthcare Worker

g. Healthcare Worker Educational Training and Motivational Program

h. Institutional Responsibility and Role of Administrators

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by ward or by service. Provide feedback to personnel regarding their

B. Standard and Transmission-Based Precaution

(which involves an intermediate carrier like an environmental surface or

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evaporative condensers, reservoirs for the causative

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or changes in the agent. Examples of mechanical transmission

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b. Administrative Control Responsibilities

C. Triage of Infectious Patients

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 The procedures at first encounter of patient need to include gathering

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i. Providing Information and facilities to patient/ accompanying person

a. Providing Information and facilities for patients/ accompanying person to

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 The Hospital has a separate well-ventilated space that allows waiting

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medically appropriate) and be notified by phone or other remote

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o Hand hygiene practices as per WHO 5 moments

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6. Patient with risk for MDRO infection and/or colonization

c. Assessment by the Physician in the clinical area of ER/OPD:

 Use of commodes by other patients in a shared room

 invasive procedures require a large aseptic working area